A. No minimum dollar amount may be imposed on any claim that is the subject of an adverse determination for a member to, and any member who receives an adverse determination may, pursue the applicable review process prescribed in this article. Except as provided in sections 20-2534 and 20-2535, health care insurers shall provide at least the following levels of review, as applicable:
1. An expedited medical review and expedited appeal pursuant to section 20-2534.
2. An initial appeal pursuant to section 20-2535.
3. An external independent review pursuant to section 20-2537.
B. For group plans, and for grandfathered individual plans, a health care insurer may elect to offer a voluntary internal appeal pursuant to section 20-2536 as an additional internal level of review after a determination of an initial appeal.
C. For individual plans and group plans for which the health care insurer does not elect to offer a voluntary internal appeal as an internal level of review, the health care insurer shall:
1. With the exception of a denial of a claim for service that has already been provided, send the member a written determination within thirty days after the health care insurer receives the appeal request.
2. For a denial of a claim for service that has already been provided, send the member a written determination within sixty days after the health care insurer receives the appeal request.
D. A health care insurer that elects to offer a voluntary internal appeal for the health care insurer's group plans shall:
1. With the exception of a denial of a claim for service that has already been provided, send the member a written determination within fifteen days after the health care insurer receives the initial appeal request and within fifteen days after the health care insurer receives the voluntary internal appeal request.
2. For a denial of a claim for a service that has already been provided, send the member its written determination within thirty days after the health care insurer receives the health care insurer receives the initial appeal request and within thirty days after the health care insurer receives the voluntary internal appeal request.
E. A health care insurer shall provide a written determination as required by this section and include the basis, criteria used, clinical reasons and rationale for the determination.
F. Except as provided in sections 20-2534 and 20-2537, a member shall be considered to have exhausted a health care insurer's internal levels of review if the health care insurer fails to comply with this article, except to the extent that the member requested or agreed to the delay, and the member may simultaneously initiate an expedited external independent review.
G. Notwithstanding subsection A, paragraph 2 of this section, a health care insurer may waive the internal appeal process.
H. At the time coverage is initiated, each health care insurer that operates in this state and whose utilization review system includes the power to affect the direct or indirect denial of requested medical or health care services or claims for medical or health care services shall include a separate information packet that is approved by the director with the member's policy, evidence of coverage or similar document. At the time coverage is renewed, each health care insurer shall include a separate statement with the member's policy, evidence of coverage or similar document that informs the member that the member can obtain a replacement packet that explains the appeal process by contacting a specific department and telephone number. A health care insurer shall also provide a copy of the information packet to the member or the member's treating provider on request and shall prominently display a copy of the approved information packet on its website. The information packet provided by the health care insurer shall include all of the following information:
1. A detailed description and explanation of each level of review prescribed in subsections A and B of this section and notice of the member's right to proceed to the next level of review if the prior review is unsuccessful.
2. An explanation of the procedures that the member must follow, including the applicable time periods, for each applicable level of review prescribed in subsections A, B, C and D of this section and an explanation of how the member may obtain the member's medical records pursuant to title 12, chapter 13, article 7.1.
3. The specific title and department of the person and the address, telephone number and fax number or email address of the person whom the member must notify at each applicable level of review prescribed in subsections A and B of this section in order to pursue that level of review.
4. The specific title and department of the person and the address, telephone number and fax number or email address of the person who will be responsible for processing that review.
5. A notice that if the member decides to pursue an appeal the member must provide the person who will be responsible for processing the appeal with any material justification or documentation for the appeal at the time that the member files the written appeal.
6. A description of the utilization review agent's and health care insurer's roles at each applicable level of review prescribed by subsections A, B, C and D of this section and an outline of the director's role during the external independent review process, if not already described in response to paragraph 1 of this subsection.
7. A notice that if the member participates in the process of review pursuant to this article the member waives any privilege of confidentiality of the member's medical records regarding any person who examined or will examine the member's medical records in connection with that review process for the medical condition under review.
8. A statement that the member is not responsible for the costs of any external independent review.
9. Standardized forms that are prescribed by the department and that a member may use to file and pursue an appeal.
10. The name and telephone number for the department of insurance and financial institutions consumer assistance office with a statement that the department of insurance and financial institutions consumer assistance office can assist consumers with questions about the health care appeals process.
I. At the time of issuing a denial, the health care insurer shall notify the member of the right to appeal under this article. A health care insurer that issues an explanation of benefits document shall satisfy this obligation by prominently displaying in the document a statement about the right to appeal. A health care insurer that does not issue an explanation of benefits document shall satisfy this obligation through some other reasonable means to assure that the member is apprised of the right to appeal at the time of a denial. A reasonable means that includes giving the member's treating provider a form statement about the right to appeal shall require the treating provider to notify the member of the member's right to appeal.
J. Any written notice, acknowledgment, request, determination or other written document that is sent by mail is deemed received by the person to whom the document is properly addressed on the fifth business day after mailing.
K. The director shall require any member who files a complaint with the department relating to an adverse determination to pursue the review process prescribed in this article. This subsection does not limit the director's authority pursuant to chapter 1, article 2 of this title.
L. If the member's complaint involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the claim or service is covered, the initial appeal process shall be performed as prescribed by section 20-2535 by a licensed health care professional. If the member's complaint involves an issue of medical necessity or appropriateness, including health care setting, level of care or effectiveness of a covered benefit, or is experimental or investigational under the coverage document and not whether the claim or service is covered, the expedited review or voluntary internal appeal shall be decided by a physician, provider or other health care professional as prescribed by section 20-2534 or 20-2536. Any external independent review shall be decided by a physician, provider or other health care professional as prescribed by section 20-2537.
M. Before a health care insurer makes a final internal adverse determination that relies on new or additional evidence generated directly or indirectly by the health care insurer, the health care insurer shall provide the new or additional information to the member free of charge sufficiently in advance of the final adverse determination to allow the member a reasonable opportunity to respond within the applicable time frames for the health care insurer to provide the member with a written determination prescribed in subsections C and D of this section.
N. Any person given access to a member's medical records or other medical information in connection with proceedings pursuant to this article shall maintain the confidentiality of the records or information in accordance with title 12, chapter 13, article 7.1.